Accurate risk adjustment in the context of value-based healthcare depends on careful HCC (Hierarchical Condition Category) coding. HCC codes affect Medicare and Medicaid patients’ payment directly by converting diagnosis into a risk score. This article explores ways to increase HCC coding effectiveness and accuracy, protecting your company’s finances while providing top-notch patient care.
What is the HCC risk adjustment model?
Utilize the HCC risk adjustment coding methodology to estimate risk scores and forecast future healthcare expenses. More precisely, CMS employs risk adjustment models to calculate capitated payments paid to MA plans and performs recurring changes intended to enhance the models’ performance, as stated in the white paper “CMS HCC Risk Adjustment Model 2019: Winners and Losers.” CMS’s list of HCCs for calculating payments to MA plans is a crucial part of the risk adjustment approach.
Understanding the Impact of Accurate HCC Coding
A key component of risk adjustment, which groups patients according to their health condition, is HCC coding. Higher risk ratings correspond to higher anticipated healthcare use, which raises payment. Precise HCC coding guarantees that you include all pertinent diagnoses, accurately representing the actual complexity of your patient group. This corresponds to:
- Just Compensation: Precise risk adjustment solutions ensure that high-risk patient management receives just reimbursement.
- Better Resource Allocation: Better resource allocation results from an understanding of patients’ requirements, which enhances the provision of healthcare.
- Improved Care Quality: Having a comprehensive picture of a patient’s health allows for better clinical judgment.
How to improve HCC coding accuracy
The good news is that your code team does not have to endure a laborious process in order to provide accurate and efficient HCC coding documentation. This is particularly true if risk adjustment vendors are using advanced data analytics to boost coding procedures’ accuracy and productivity in order to prevent significant revenue and compliance gaps. While having the means and instruments to deliver precise data is an excellent place to start, do not stop there. There are three excellent strategies to increase the efficiency and quality of HCC coding documentation:
Ensure audit preparedness
The purpose of CMS’s Risk Adjustment Validation audit program is to find and stop incorrect MA payments in the past and future, which can be expensive for health plans. Providing a comprehensive member risk profile should be the top focus of a health plan organization’s risk adjustment solutions accuracy program. In order to better understand its member population, guide care decisions, and enhance health outcomes. Thus, there is less exposure to danger. Access to automated analytics software solutions that give coders documented clinical evidence of accurate coding between the medical record and claim codes is a feature of a successful risk adjustment accuracy program. These instruments considerably lessen risk exposure and streamline the reconciliation process.
Review patient data
Finding chronic illnesses, controlling expenses, and determining precise HCC risk scores and reimbursements are the first steps in improving patient care. It is possible to collect and evaluate vast volumes of diverse data and discover risk score-relevant situations more quickly than with the traditional review procedure. By using technologies like machine learning and natural language processing to provide medical coders with data-driven insights. Using technology in these areas can help you detect missed HCC conditions sooner and resolve documentation gaps more quickly and accurately. This could be the difference between getting transfer funds or not.
Automate manual processes
Since fewer time-consuming record evaluations are required now, you can more easily shorten the traditional risk adjustment accuracy procedure thanks to technological advancements. Coding teams are now more efficient since they can process patient records more accurately and on a grander scale. The backbone of an automated process is having it incorporated into your coders’ workflow, providing tremendous productivity. Health plans can more readily handle issues related to the rise in MA enrollment if they integrate natural language processing technologies into their operations.
HCC Coding Guidelines
While the HCC model is not particularly intuitive, this was not intentional while designing the HCC coding procedure. Instead, the goal is to give a precise and comprehensive overview of every member’s risk profile in order to understand their health better and estimate healthcare costs. In order to more fully understand how everything functions to benefit society as a whole. Let us look at how each eligible MA beneficiary’s Risk Adjustment Factor (RAF) point value influences patient outcomes and allows for payment for therapy.
Ensuring appropriate reimbursement benefits all parties involved, including the member, health plan, provider, and CMS. Documentation of RAFs must adhere to CMS-established requirements. According to the guidelines, documentation in a medical record must be based on in-person interactions between a patient and a healthcare provider, coded in compliance with the ICD-10-CM Guidelines for Coding and Reporting, assigned based on service dates during the data collection period, and originate from a hospital or acceptable RA physician specialty.
Investing in the Future of HCC Coding
Healthcare companies can establish a culture of quality care and create a solid financial foundation by giving priority to efficiency and accuracy in HCC coding. It will be essential to stay up to date on technological breakthroughs, laws, and best practices as the healthcare sector changes. Recall that precise HCC coding is a continuous process rather than a one-time solution. Risk adjustment vendors can make sure that their company stays well-positioned for success in the value-based healthcare market by iteratively improving their strategy.
Conclusion
Providing patients with high-quality care and optimizing compensation depends heavily on the efficiency and accuracy of HCC coding. Healthcare organizations can establish a robust system for recording all pertinent diagnoses, leading to suitable risk ratings and ideal financial health, by putting the above-mentioned ideas into practice. Keep in mind that proper HCC coding is essential for more reasons than just compensation; it also helps to guarantee that patients with complicated requirements get the resources they are due.